Renal

8. A 78-year-old patient is admitted to the

hospital with dehydration and electrolyte

imbalance. The patient is confused and

incontinent of urine on admission. In developing

a plan of care for the patient, an appropriate

nursing intervention for the patient's incontinence

is to

a. insert an indwelling catheter.

b. apply absorbent incontinent pads.

c. assist the patient to the bathroom q2hr.

d. restrict fluids after the evening meal.: Answer: C

Rationale: In older or confused patients, incontinence may

be avoided by using scheduled toileting times. Indwelling

catheters increase the risk for UTI. Incontinent pads

increase the risk for skin breakdown. Restricting fluids is

not appropriate in a patient with dehydration.

Cognitive Level: Application Text Reference: pp. 1183-

1185

Nursing Process: Planning NCLEX: Physiological Integrity

6. In planning teaching for a patient with benign

nephrosclerosis, the nurse should include

instructions regarding

a. measuring daily intake and output amounts.

b. obtaining and documenting daily weights.

c. monitoring and recording blood pressure.

d. preventing bleeding caused by anticoagulants.:Answer: C

Rationale: Hypertension is the major symptom of

nephrosclerosis. Measurements of intake and output

and daily weights are not necessary unless the patient

develops renal insufficiency. Anticoagulants are not used

to treat nephrosclerosis.

Cognitive Level: Application Text Reference: p. 1175

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

RenalStudy online at quizlet.com/_bwmm8

2. The nurse establishes a nursing diagnosis of

excess fluid volume related to inflammation at

the glomerular basement membrane in a patient

with acute glomerulonephritis. To best evaluate

whether the problem identified in the nursing

diagnosis has resolved, the nurse will monitor for

a. proteinuria.

b. elevated creatinine.

c. periorbital edema.

d. hematuria.: Answer: C

Rationale: Resolution of the excess fluid volume is best

evaluated by changes in edema. The other data may

indicate whether the glomerulonephritis is resolving but do

not provide data about fluid volume.


Nursing Process: Evaluation NCLEX: Physiological

Integrity

10. A nurse is caring for a client with chronic renal failure.The laboratory

results indicate hypocalcemia and hyperphosphatemia.When

assessing the client, the nurse should be alert for whichof the

following? SELECT ALL THAT APPLY.

1) Trousseau's sign

2) Cardiac arrhythmia

3) Constipation

4) Decreased clotting time

5) Drowsiness and lethargy

6) Fractures: RATIONALE: 1, 2, 6.

Hypocalcemia is a calcium deficit that

causes irritability and repetitive muscle

spasms.

S/S of hypocalcemia include

Trousseau's sign, cardiac arrhythmias,

diarrhea, increased clotting times,

anxiety, and irritability.

The calcium-phosphorus imbalance

leads to brittle bones and pathologic

fractures

5. A patient is admitted to the hospital with

nephrotic syndrome after taking an OTC

nonsteroidal antiinflammatory drug (NSAID) a

week earlier. Which assessment data will the

nurse expect to find related to this illness?

a. Low blood pressure

b. Recent weight gain

c. Poor skin turgor

d. High urine ketones: Answer: B

Rationale: The patient with a rapid-onset nephrotic

syndrome will have rapid weight gain associated with

edema. Hypertension is a clinical manifestation of

nephrotic syndrome. Skin turgor is normal because of the

edema. Urine protein is high.


Nursing Process: Assessment NCLEX: Physiological

Integrity

9. A patient undergoes a nephrectomy for

massive trauma to the kidney resulting from

a fall from a scaffold. Which assessment data

obtained postoperatively are most important to

communicate to the surgeon?

a. Blood pressure is 102/48.

b. Urine output is 20 ml/hr for 2 hours.

c. Crackles are heard at both lung bases.

d. Incisional pain level is 8/10.: Answer: B

Rationale: Because the urine output should be at least

0.5 ml/kg/hr, a 40-ml output for 2 hours indicates that the

patient may have decreased renal perfusion because

of bleeding, inadequate fluid intake, or obstruction at

the suture site. The blood pressure requires ongoing

monitoring but does not indicate inadequate perfusion at

this time. The patient should cough and deep breathe,

but the crackles do not indicate a need for an immediate

change in therapy. The incisional pain should be

addressed, but this is not as potentially life-threatening

as decreased renal perfusion. In addition, the nurse can

medicate the patient for pain.



Integrity

4. A patient who is diagnosed with nephrotic

syndrome has 3+ ankle and leg edema and

ascites. Which nursing diagnosis is a priority for

the patient?

a. Fluid-volume excess related to low serum

protein levels

b. Altered nutrition: less than required related to

protein restriction

c. Activity intolerance related to increased weight

and fatigue

d. Disturbed body image related to peripheral

edema and ascites: Answer: A

Rationale: The patient has massive edema, so the priority

problem at this time is the excess of fluid volume. The

other nursing diagnoses are also appropriate, but the focus

of nursing care should be resolution of the edema and

ascites.

Cognitive Level: Application Text Reference: pp. 1167-

1168

Nursing Process: Diagnosis NCLEX: Physiological Integrity

3. A patient with nephrotic syndrome develops

flank pain. The nurse will anticipate treatment

a. antibiotics.

b. antihypertensives.

c. anticoagulants.

d. corticosteroids.: Answer: C

Rationale: Flank pain in a patient with nephrosis suggests

a renal vein thrombosis, and anticoagulation is needed.

Antibiotics are used to treat a patient with flank pain

caused by pyelonephritis. Antihypertensives are used if

the patient has high blood pressure. Corticosteroids may

be used to treat nephrotic syndrome but will not resolve a

thrombosis.


Nursing Process: Planning NCLEX: Physiological Integrity1. When admitting a patient with acute

glomerulonephritis, the nurse will ask the patient

about

a. history of high blood pressure.

b. frequency of UTIs.

c. recent sore throat and fever.

d. family history of kidney disease.: Answer: C

Rationale: Acute glomerulonephritis frequently occurs

after a streptococcal infection such as strep throat. It is not

caused by hypertension, UTI, or related to family history.



7. When obtaining the health history for a

30-year-old patient who smokes two packs of

cigarettes daily, the nurse will plan to do teaching

about the increased risk for

a. interstitial cystitis.

b. UTI.

c. kidney stones.

d. bladder cancer.: Answer: D

Rationale: Cigarette smoking is a risk factor for bladder

cancer. The patient's risk for developing interstitial cystitis,

UTI, or kidney stones will not be reduced by quitting

smoking.


Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

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